| NPI | 1922130053 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC1900X Psychologist Counseling (Licence: MN LP5070) |
| Additional Taxonomies | 103TM1800X Psychologist Mental Retardation & Developmental Disabilities (Licence: MN LP5070) |
| Enumeration Date | 2007-03-12 |
| Last Update Date | 2014-10-17 |